ACOFS Case Report VOL I ISSUE V

Cavernous Sinus Thrombosis: A Case Report

Gaurav Verma1, Arunesh Kumar Tiwari2,
Fahad Ahmad3, Palavi Gupta4, www.acofs.com
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ABSTRACT
Cavernous sinus thrombosis or thrombophlebitis is a this article online in our databse
major life threatening complication of orofacial infections. Article Code: ACOFS0020
The diagnosis was based on case history and clinical pres-
entation of the condition. We presented a case of cav-
ernous sinus thrombosis presented with typical features
involving the eye with a maxillary tooth as a focus of
infection. The patient was treated by aggressive measures
which includes supportive therapy along with surgical
management.

Keywords:Cavernous Sinus; Cavernous Sinus Thrombosis;

Cavernous Sinus Thrombophlebitis;Chemosis;Ophthalm
oplegia; Ptosis.
How to cite this Article:Verma G, Tiwari A.K, Ahmad F,
Gupta P. Cavernous Sinus Thrombosis:A Case Report. Arch
CranOroFac Sc 2014;1(5):63-65.
Source of Support: Nil.
Conflict of Interest:No.
INTRODUCTION
Cavernous sinus thrombosis or thrombophlebitis (CST) is a major
life threatening complication of orofacial infections [1]. We pre-
sented a case of cavernous sinus thrombosis presented with typi-
cal features of the condition. The diagnosis was based on case his-
tory and clinical presentation. The management of patient
includes supportive therapy along with surgical management.
Aggressive management is advocated to treat this life threatening
condition.
CASE REPORT
A 12 year old female child patient, reported with a chief com-
plaint of pain in the left eyes along with swelling since 10 days.
The swelling of the left eye increases rapidly over a period of 10
days to that of present size along with increased redness. The
other associated symptoms were fever and severe headache.
General physical examination revealed that the patient was
markedly ill. The extra-oral examination revealed generalized dif-
fuse swelling (cellulitis) of the left side of the face. An ophthalo-
mologist performed the detailed examination of the eye. Both
upper and lower eyelids of the left side were swollen along with
ptosis of the upper eyelid. The eyeball is bulging outward i.e.
exophthalmos/ proptosis was evident. There is chemosis of the
bulbar conjunctiva, dilatation of the pupil along with retinal hem-
Fig.1: Clinical examination revealed edema of eyelids, ptosis, proptosis,
chemosis, retinal hemorrhages, dilatation of pupil, cellulitis of left side of face.
orrhages (Figure.1). The corneal reflex was absent. There is
increased lacrimation along with decrease in visual acuity.
Complete closure of the eye is not possible because of paresis of
extra-ocular muscles. The patient presented with high grade fever
(1010 F) and increased pulse rate (120 beats per minute). Blood
pressure and respiratory rate were within normal limits.
Neurosurgical examination of the patient ruled out the presence
of the meningitis.
Further questioning from the patient revealed that the patient
have a tooth ache in the upper front tooth prior to onset of the
symptoms. On examination, oral hygiene of the patient was poor.
There were multiple carious teeth in the jaws. The painful tooth
in consideration was upper left central incisor with discolored
crown and was tender on percussion. Patient was advised blood
investigations and OPG radiographic examination. Blood investi-
gations showed increased leucocyte count with relative neu-
trophilia and elevated erythrocyte sedimentation rate (ESR).
Further, blood culturing was advised to identify the pathogenic
microorganism along with antibiotic sensitivity testing. OPG
examination revealed periapical pathology in relation to upper
left central incisor (culprit tooth in consideration) (Figure.2).
There was history of trauma 2 years back to this tooth while play-
ing. Trauma to the tooth with subsequent necrosis of pulp and
development of periapical pathology was the probable etiology.

Archives of CraniOroFacial Sciences, December-January 2014;1(5):63-65 63

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ACOFS Cavernous Sinus Thrombosis: A Case Report
Fig.2: OPG examination revealed periapical pathology in relation to left
maxillary central incisor (culprit tooth) along with multiple carious teeth.
The condition was diagnosed as cavernous sinus thrombosis
based on case history, clinical presentation and routine investiga-
tions.
Patient was admitted to the hospital for management. The
management protocol includes supportive therapy and surgical
management. Supportive therapy includes hydration of the
patient with intravenous solution, proper nutrition and adminis-
tration of antibiotic therapy. Chloramphenicol (1 gram 6 hourly)
was administered by intravenous route on empirical basis. As the
use of anticoagulant is controversial, we have not used anticoag-
ulant in our case. The dental management includes the access
opening preparation in the upper left central incisor to establish
decompression of the periapical area. The supportive therapy
includes oral hygiene maintenance by frequent irrigation of the
root canal along with oral cavity using chlorhexidine (0.2%).
Chlorhexidine (0.2%) was further prescribed to patient for regu-
lar use 2-3 times per day. Non steroidal anti-inflammatory drugs
(NSAIDs) were prescribed to the patient for analgesic and anti-
pyretic action. Eye care include use of antibiotic-steroid eye
drops, use of lubricants and frequent eye wash using sterile water
as per the advice of ophthalmologist.
There was marked improvement in the condition of the
patient with a good control of acute toxic symptoms of the dis-
ease. As the acute symptoms were under control, it was planned
to extract the upper left central incisor under antibiotic cover. The
tooth was extracted along with generous curettage to remove the
periapical pathology. The socket was irrigated with the betadine
solution (5%) and the extraction socket was closed with 3-0 black
silk suture.
The blood culture and sensitivity report revealed that the
infection is primarily of mixed origin with predominance of strep-
tococci group. The microbial flora was sensitive to amoxicillin
and metronidazole commonly used in clinical practice. Based on
this report the patient was prescribed tablet augmentin (amoxi-
cillin + clavulanic acid combination) 625 mg twice daily, tablet
metronidazole 400 mg thrice daily for next 7 days. Sutures were
www.acofs.com
VOL I ISSUE V
removed after 7 days of extraction. The patient was further
advised to undergo complete management of other dental dis-
eases to avoid infections in future.
DISCUSSION
Cavernous sinus thrombosis or thrombophlebitis (CST) is a
serious condition characterized by formation of thrombus either
in the cavernous sinus or its communicating branches.
Infections of the face, head and intra-oral structures especially
above the maxilla are more prone to produce CST. The infec-
tion can reach the cavernous sinus by two routes. Infections
from the face and lips are carried by the facial and angular
veins, while pterygoid plexus carried the dental infection. The
spread of the infection by the external route via facial vein is
rapid with a short fulmination course. The reason for this is
that, the veins of the face are of larger diameter and have no
valves i.e. open channels. On the other hand, infections spread-
ing via internal route or through pterygoid plexus of veins
reaches cavernous sinus after passing through multiple small
twisted passages leading to slower course [1]. Our patient pre-
sented with rapid onset of the condition in contrast with usual
slow presentation in most cases. This can be explained by the
fact that the periapical infections from the maxillary central
incisors mostly spread through the labial cortex toward the lips
or face as the root apex is closer to labial cortical plate.
CST may be caused either by direct extension through the
venous system (septic thrombophlebitis) or by spread of infect-
ed emboli. The initial symptoms of CST are usually pain in the
eyes and tenderness to pressure. The other symptoms of the tox-
icity include fever with chills, excessive sweating and increased
pulse rate. The signs of the venous obstruction are edema of the
eyelids, proptosis and chemosis. There may be increased
lacrimation and retinal hemorrhage. The involvement of
trochlear, occulomotor, abducens, ophthalmic division of the
trigeminal nerve and carotid plexus leads to ophthalmoplegia,
dilatation of the pupils, ptosis and diminished or absent corneal
reflex. In advanced stages there may be development of tox-
emia and meningitis. If the treatment is not immediately done,
the prognosis is usually poor even in the antibiotic era [2].
For management of CST, Chloramphenicol 1 gram 6 hourly
by intravenous route is the drug of choice. To identify the
causative microorganism the culture can be taken from the
source of infection or by the blood culture. Also, culturing will
help in determining the antibiotic sensitivity of the causative
microorganisms. Various authors have reported streptococci,
staphylococci and gram negative microbes to be involved in the
pathogenesis of CST [2]. We have used chloramphencol for
empirical therapy and shifted the patient to definite therapy
(augmentin and metronidazole) based on the reports of blood
culture and sensitivity testing.
Some authors advocated the use of anticoagulants to pre-
vent venous thrombosis. However, the efficacy of this treatment
is not well established. There are few authors who argued
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ACOFS Cavernous Sinus Thrombosis: A Case Report VOL I ISSUE V

against the use of anticoagulants and stated that its use can
aggravate the hemorrhagic lesions in the brain and once the 4. Dr. Palavi Gupta,
condition is established such drugs are useless [2]. As the use Postgraduate Student,
of anticoagulant is controversial, we have not used anticoagu- Department of Oral and Maxillofacial Surgery,
lant in our case. Punjab Govt. Dental College & Hospital,
CONCLUSION Amritsar, India.
Phone Number- +919888762994
Cavernous sinus thrombosis or thrombophlebitis (CST) is a E- Mail:palvi.27nov@gmail.com
life threatening condition which can lead to fatal outcomes. The
comprehensive management of the patient includes a collective
team work of oral surgeon, neurosurgeon and ophthalmologist for
diagnosis as well as the management of the condition. The man-
agement of CST should be aggressive and include both support-
ive and surgical therapy.
REFERENCES
1. Rajendran R, Sivapathasundharam B. Shafer's Text Book of
Oral Pathology. 5th ed. New Delhi: Reed Elsevier India
Limited; 2008.
2. Laskin DM. Oral and Maxillofacial Surgery (Volume Two
Oral Surgery). AITBS Indian Ed. New Delhi: AITBS
Publisher; 2009.

Authors
1. Dr. Gaurav Verma
MDS
Senior Lecturer,
Department of Oral and Maxillofacial Surgery,
Himachal Institute of Dental Sciences,
Paonta Sahib, Himachal Pradesh, India.
Mailing Address- House No. 521-A, Model Town, Yamuna
Nagar, Haryana, India. Pin Code 135001.
Phone Number- +919736565635
E -Mail:gauravjournals107@gmail.com

2. Dr. Arunesh Kumar Tiwari

MDS
Senior Lecturer,
Department of Oral and Maxillofacial Surgery,
Sardar Patel Postgraduate Institute of Dental and Medical
Sciences,Lukhnow, India.
Phone Number- +918765183953
E- Mail: aruneshtiwari11@yahoo.com

3. Dr. Fahad Ahmad

Postgraduate Student,
Department of Oral and Maxillofacial Surgery,
Punjab Govt. Dental College & Hospital,
Amritsar, India.
Phone Number- +919988162459
E- Mail: drfahadahmad@gmail.com

Archives of CraniOroFacial Sciences,December-January 2014;1(5):63-65 65